Woman's long-term care policy not honored

Correction: An earlier version of this story said the complaint said Dr. Patricia McKeon declined to interview O' Brien's children despite CNA's instruction. CNA told her not interview O' Brien's children after she insisted, she said.

Janice O'Brien might have dementia, but she still thinks she knows when she has been had.

A Southern California law firm filed a complaint in Monterey County Superior Court alleging O'Brien, a well-known 91-year-old Pebble Beach resident, has been the victim of an "unfair and unlawful scheme" to deny her health coverage that she paid for.

O'Brien's Chicago insurance company, CNA Insurance, ignored the advice of three doctors — including its own — in processing claims for O'Brien's medical bills, the complaint says.

CNA Insurance spokeswoman Jennifer Martinez-Roth said Tuesday the company hadn't been served with the complaint yet, but after reading a copy provided by The Herald, she rejected its findings.

"We do disagree with her assertions and we will defend ourselves against this lawsuit," she said.

Attorney Samuel Bruchey of the Shernoff Bidart Echeverria Bentley law firm said O'Brien's family was referred to his firm — known for suing insurance companies — by a Monterey lawyer.

Bruchey said O'Brien's case was "egregious" because people such as her buy long-term care policies to not be a burden on their families when they get older.

"These insurance companies put all of these ridiculous hurdles they need to overcome just to get the benefits the insurance company promised from the start," he said.

O'Brien is a well-known activist in the area, especially on land-use and environmental issues. She is a past president of the League of Women Voters of the Monterey Peninsula and ran for seats on the Monterey Peninsula Water Management District. One of her seven children, Pete O'Brien, is a former Major League Baseball player for the Texas Rangers, Cleveland Indians and Seattle Mariners.

In 1996, Janice O'Brien purchased long-term care insurance from CNA. She paid all of her premiums on time, according to the complaint, and still pays $4,998 a year.

In July 2011, she was admitted to a hospital with weakness and hyponatremia, the complaint says, which led her doctor and family to determine she should not live alone.

The family hired caregivers to go to her home to assist in daily activities. They submitted claims to CNA based on the criteria for O'Brien's policy on home care providers, the complaint says.

Dr. David Straface, O'Brien's Monterey physician, also provided evidence she required supervision because of hypertension, hyponatremia and cognitive impairment, the complaint says.

The insurance company told the family she would need to be evaluated by the company's own nurse in October 2011, according to the complaint.

The nurse said O'Brien did not need assistance and had normal cognitive functioning, the complaint says. CNA rejected all of O'Brien's claims.

O'Brien's family spent the next several months appealing the decision while her condition worsened.

She continued to see Straface, who treated her for "increased bouts of dizziness," diagnosed her with mild dementia and noted she probably had early Alzheimer's disease, the complaint says.

Dr. Alejandro Centurion, a Carmel neurologist, also treated O'Brien. He said she could not prepare meals and needed assistance with almost all aspects of daily life.

In November 2012, the complaint says, CNA paid its own independent medical examiner, Dr. Patricia McKeon, to evaluate O'Brien. McKeon is a Pacific Grove clinical psychologist specializing in dementia, traumatic brain injury and memory disorders, according to her website, Drtrishmckeon.com.

McKeon seemingly backed up O'Brien's doctors' claims, stating she scored "well below average" in functional cognitive skills tests and that her condition was "very much consistent with a diagnosis of Alzheimer's disease," according to the complaint.

The complaint, which asks for a jury trial, seeks damages, plus interest, and an unspecified amount of money for emotional distress and other damages.

CNA is the seventh-largest commercial insurer in the country and the 13th-largest property and casualty insurer, according to its website. It provides a vast variety of insurances for businesses and people.

It had a net income of $628 million last year, according to its filings with the U.S. Securities and Exchange Commission.